O Irion, P Hirsbrunner Almagbaly, A Morabia (Univ Hosp of Geneva).
Planned Vaginal Delivery Versus Elective Cesarean Section: A Study of 705 Singleton Term Breech Presentations.
Br J Obstet Gynaecol 105: 710-717, 1998.
There were 705 singleton term breech presentations. Of these 385 were planned vaginal deliveries and 320 were elective cesarean sections.
Results : In the planned vaginal delivery group, there were significantly fewer maternal complications than in the elective cesarean section group, with a risk difference of 10.5%. Death occurred in 5 neonates with major malformations. Between the planned vaginal delivery and the elective cesarean section groups, there was no difference in corrected neonatal morbidity with a risk of difference of 1.9%.
The author A.A. Fanaroff, conclude that there is no firm evidence to recommend systematic elective cesarean section for a breech presentation at term.
Editorial comment – In the USA the trainees in obstetrics do not have the opportunity to learn how to deliver a breech vaginally and never acquire the considerable skill necessary to do so. External Cephalic Version (ECV ) has made a resurgence in the past 15 years because of a strong safety record and a success rate of about 65%.
The only thing to be kept in mind is while doing prime cesarean section is the high odds ratio of recurrence of breech and hence repeat section.
SL Clark, W Xu, TF Porter, et al (Univ of Utah, Salt Lake City)
Institutional Influences on the Primary Cesarean Section rate in Utah 1992 to 1995
Am J Obstet Gynecol 179: 841-845, 1998.
The review covered all deliveries occurring in general acute-care hospitals in Utah from 1992 to 1995.
It was found that cesarean delivery rates declined significantly during the study period. Factors reducing the cesarean delivery rate on 1-way analysis of variance were availability of a newborn ICU and maternal-fetal medicine subspecialists; presence of obstetrician-gynecologists on staff rather than family physicians only; delivery volume of greater than 1500 per year; urban location; and 24-hour in-house anesthesiology services. Thus there was a fall in percentage of cesarean section of 18% in 1990 to 15% in 1997 in LDS hospital.
MJ Paech, R Godkin, S Webster (King Edward Mem Hosp for Women, Perth, Australia)
Complications of Obstetric Epidural Analgesia and Anaesthesia: A Prospective Analysis of 10,995 cases.
Int J Obstet Anesth 7: 5-11, 1998.
During a 5-year period, prospective data were collected on 10,995 obstetric epidural blocks performed for labor in 1 institution. During this period, the epidural analgesia rate during labor was 33% to 36%, and the cesarean section rate was 18% to 23%.
Epidural analgesia for labor was the primary indication for 7648 women, whereas for 3311 women, the primary indication for anesthesia was cesarean section. Failed or abandoned insertion occurred in 0.5%, reinsertion in 5%, inadequate anesthesia in 1.7%, and inadequate analgesia in 0.9%. In addition to its minor complications there are 8 occasions, unexpectedly high blocks occurred comprising of 0.07% with 2 women requiring intubation and ventilation. Mild respiratory depression after postoperative epidural opioid occurred in 3 women.
Conclusion: An effective obstetric epidural service is possible with few serious complications. Maternal mortality is now rarely caused by epidural anesthesia. Current practices in obstetric epidural analgesia and anesthesia are safer than in the past.
J Berard, P Dufour, D Vinatier, et al (Hopital Jeanne de Flandre, Lille cedex, France)
Fetal Macrosomia: Risk factors and Outcome: A Study of the Outcome Concerning 100 Cases > 4500 g.
Eur J Obstet Gynecol Reprod Biol 77: 51-59, 1998.
Method: A retrospective review was conducted of 100 infants with weights of at least 4500g. The mode of delivery and incidence of maternal and perinatal complications were reviewed. Ten of these infants had a birthweight of more than 5000g. The mean birthweight was 4730g and the maximum was 5780g.
Results : In 19 mothers, gestational diabetes was present. In 3 women, diabetes was present. In 87 women, a trial of labor was allowed, and 13 women had elective cesarean delivery. The overall cesarean rate was 36%, which included elective cesarean delivery and failed trial of labor. Vaginal deliveries were performed in 73% of those having a trial of labor. In 14 infants, shoulder dystocia occurred in 22% of vaginal deliveries. In this series, it was the most frequent complication. Five infants had Erb’s palsy with humeral fracture associated in 1 infant.
Conclusion: For infants with estimated birthweights of less than 5000g and a trial of labor, vaginal delivery is a reasonable alternative to elective cesarean section. Elective cesarean section should be recommended for fetuses with an estimated birthweight of more than 5000g, particularly in primiparous women.
Gregory and colleagues identified term, singleton, macrosomic (at least 4000g) infants from Washington State and found that the incidence was 13%. Macrosomia appears to be the single important factor associated with shoulder dystocia which, even in the presence of significant risk factors, remain largely unpredictable.
MH Beall, C Spong, et al (Harbor-Univ of California, Los Angeles)
Objective Definition of Shoulder Dystocia: A Prospective Evaluation.
Am J Obstet Gynecol 179: 934-937, 1998.
A potentially devastating obstetric complication- shoulder dystocia- occurs in 0.5% of births. Shoulder dystocia has been associated with maternal factors such as gestational diabetes, obesity, weight gain, prolongation of the second stage of labor, operative vaginal delivery, and macrosomia.
The authors have studied seven hundred twenty two vaginal deliveries in a 2-year period for head-to-body delivery time and use of ancilliary obstetric maneuvers. They found that there were 623 deliveries with no shoulder dystocia and 99 deliveries with shoulder dystocia. Shoulder dystocia group had all the fetal injuries. A diagnosis of shoulder dystocia was significantly associated with duration of the second stage of labor.
Editorial comment : The prolonged head-to-body time should not be difficult to document and should be documented to find out the real incidence of shoulder dystocia.
TS Nesbitt, WM Gilbert, (Univ of california, Davis; Univ of California, Berkeley)
Shoulder Dystocia and Associated Risk Factors With Macrosomic Infants Born in California.
Am J Obstet Gynecol 179: 476-480, 1998.
They have studied 175,886 vaginal births of infants weighting more than 3500g, of whom 6238 infants (3%) had shoulder dystocia in a 1-year period.
They came to the conclusion when counseling patients when macrosomia is suspected, this information on the incidence of shoulder dystocia and associated risk factors for a large statewide population may assist providers of obstetric care. A severe limitation in attempting to establish guidelines designed to prevent shoulder dystocia is the inaccuracy of estimating fetal weight.
Langer reported that the incidence of macrosomia was almost threefold greater among diabetic women (21.6%) than nondiabetics (7.6%), and he and Conway used an ultrasound estimated weight threshold (4250gm or greater) as an indication for elective delivery in diabetic women.
As the risks for birth trauma and asphyxia escalate with increased fetal growth, the recommendation for cesarean section, if the estimated weight of the fetus is more than 4500g appears justified. Nonetheless, 61% of such infants were delivered vaginally and relatively few were permanently injured.
Of note in the database is the fact that 44% of infants with brachial plexus injuries reported in the birth records did not have the diagnosis of shoulder dystocia recorded. This probably reflects both underreporting of shoulder dystocia and other mechanisms for injuries to the brachial plexus.
BM Petrikovsky, E Schneider, et al (New York Univ, Manhasset)
Cephalhematoma and Caput Succedaneum: Do They Always Occur in Labor?
Am J Obstet Gynecol 179: 906-908, 1998.
There were 7 instances of cephalhematomas and caput succedaneum that were identified prenatally. All patients had a comprehensive ultrasonographic examination that included an assessment of the fetal head and neck. A neonatologist confirmed the final diagnosis of cephalhematoma vs.caput succedeneum. To rule out intracranial bleeding or skull fractures, ultrasonography of the neonatal head was performed.
Results : In 5 infants, cephalhematomas appeared as an echogenic bulge posterior to the occipital region of the fetal head, and in 2 infants, they appeared at the temporal region of the fetal head. Forceps or vacuum extraction were not used on any of the affected infants. The formation of cephalhematoma was strongly associated with station of the presenting part, presence of asynclitism and increasing application to delivery time.
Conclusion: Cephalhematomas are believed to result from operative delivery, but they can also originate in utero and antepartum. An associated factor appears to be premature rupture of the membrane. Causes other than birth trauma include head compression by the uterine walls, as seen in the setting of oligohydramnios after premature rupture of membranes.
Editorial comments: To the uninitiated, and even the experienced observer, a cephalhematoma before delivery in the fetus may mimic an encephalocele.
Clinicians need to be alerted to another relatively uncommon but very dramatic complication most often associated with vacuum deliveries, namely subgaleal hematomas (SGH). Chadwick was able to identify 37 infants with subgaleal hematomas over a 24 year period. All except 1 of the neonates had instrumental deliveries; 89% had a vacuum extractor applied to the head at some stage of delivery (vs. 10% of the general population of births in Western Australia). There was also a significantly increased risk of failure of attempted vacuum extractions, so that 45% of the neonates also had forceps applied to the head. Head trauma such as skull fracture, intracranial hemorrhage, and cerebral edema, as well as neonatal encephalopathy were common associations and the presence of a coagulopathy increased the severity of the SGH e.g Hereditary clotting disorders, including hemophilia. Although there were some early deaths, the long-term outcome for the survivors was excellent.
MV Senat, S Minoui, et al (hopital Beclere Clamart,France)
Effect of Dexamethasone and Betamethasone on Fetal Heart Rate Variability in Preterm Labour: A Randomised Study.
Br. J Obstet Gynecol 105: 749-755, 1998.
The patients were 82 pregnant women (97 fetuses) who experienced mild to moderate premature contractions between 25 and 33 weeks’ gestation. All patients had intact membranes and all who experienced more than 5 contractions per hour were treated with albuterol. The women were randomized to receive either betamethasone (n=42) or dexamethasone (n=40) to enhance fetal lung maturation.
Patients receiving betamethasone received 4 intramuscular injections of 3 mg of betamethasone sodium and 3mg of betamethasone acetate, with 12 hours between injections. Patients receiving dexamethasone received 4 intramuscular injections of 4mg of dexamethasone acetate, with 12 hours between injections. At baseline, 24 to 48 hours, and 4 to 7 days after the first injection of either corticosteroid, cardiotocograms (CTGs) were performed and their results recorded to characterize fetal cardiac parameters.
It was found that overall fetal outcomes did not differ significantly between the 2 groups. None of the 44 infants in the dexamethasone group experienced any significant changes in FHR variability or other CTG parameters throughout their treatment. However, CTG parameters changed significantly in the 53 infants in the betamethasone groups; by 24 and 48 hours, long and short-term variations were significantly shorter than at baseline and there were significantly more accelerations of more than 10 beats/min.
Conclusions: At equivalent doses, dexamethasone was associated with significantly less alteration in FHR variability than betamethasone. Both drugs effectively prevented respiratory distress.
The authors imply that, all things being equal-which they never are – dexamethasone is more desirable because it causes less FHR abnormalities. The potential blunting of the ability to recognize fetal distress by reducing FHR variability is not the major concern; we remain more concerned with the potential arrest of fetal head growth, particularly with multiple courses of these corticosteroids. It is imperative to determine whether multiple doses are necessary and if so, the safest interval between courses of antenatal steroids.
OD Saugstad, T Rootwelt, (Natl Hosp, Oslo, Norway; Univ of Oslo, Norway)
Resuscitation of Asphyxiated Newborn Infants with Room Air or Oxygen: An International Controlled Trial: The Resair 2 Study.
Pediatrics 102:e1, 1998.
Most newborn infants with asphyxia are resuscitated with 100% oxygen, although such high oxygen concentrations could generate oxygen radicals that could cause cerebral injury. Therefore, resuscitation with a lower concentration of oxygen (room air) was studied as a way to treat newborns with asphyxia.
Methods: Ten international centers, most of which were located in developing countries, enrolled 609 newborn infants with asphyxia who weighed 1000g or more into this study. Patients were allocated to receive resuscitation with either 100% oxygen (321 babies) or with room air (288 babies), and median gestational age 38 weeks. American Heart Association techniques for resuscitation were used as guidelines, with a ventilation target frequency of 40 to 60 breaths/min. The number of deaths during the first week of life was compared between the groups, as was the presence hypoxic-ischemic encephalopathy. The groups were also compared on the basis of Apgar scores, heart rate at 90 seconds, time to first breath, time to first cry and arterial blood gas and acid base status.
All other parameters were almost the same in both the groups. However, arterial partial pressure of oxygen was significantly higher in the 100% oxygen group at 30 minutes after resuscitation. The room air group had significantly better Apgar score at 1 minute. Resuscitation was considered ineffective if the infants developed bradycardia, central cyanosis or both after 90 seconds; failure rates in the 100% oxygen and room air groups were similar.
Conclusion: The resuscitation of newborn infants with asphyxia with room air is at least as successful as resuscitation with 100% oxygen. In fact, the infants receiving room air had significantly better 1-minute Apgar score, a shorter time to first cry and a shorter time to first breath. The latter difference may be explained by a possible effect of 100% oxygen in depressing ventilation. The data presented in this article may have important implications for centres in both developing and developed countries.
Editorial comment : Each year a million babies die and that an equal number suffer permanent neurologic damage as a result of birth asphyxia. In developing countries, most deliveries probably occur in the home in the presence of a traditional health care worker who may be able to deliver mouth-to-mouth resuscitation if tactile stimulation and drying the infant fail to elicit respiratory efforts. Where electrical suctioning is not available, manual suctioning e.g. with bulb syringes, and bag and mask ventilation (with self-inflating bags) available to health care workers. The study had significant limitations and was too small to prove much. One has to enroll 7000 infants to demonstrate a significant reduction in brain injury or a change in the mortality rate from 24% to 21% . Such a study is unlikely to see the light of day.
DM Casalaz, N Marlow, BD Speidel (Univ of Bristol, England; Southmead Hosp, Bristol, England)
Outcome of Resuscitation Following Unexpected Apparent Stillbirth
Arch Dis Child Fetal Neonatal Ed 78:F112-F115, 1998.
Few data are available regarding the outcome of infants born with no audible heartbeat at 1 minute and this was reviewed to evaluate the prevalence of intact survival in these infants and to identify predictors that might be of value to the clinical team.
The outcome of 42 successfully resuscitated stillborn children was reviewed with the conclusion that of the unexpected apparent stillbirths successfully resuscitated, 52% died or survived severely disabled. About 10% had an equivocal outcome and 36% survived apparently intact. In these circumstances, vigorous resuscitation is clearly indicated.
Editor comments : Unexpected Apparent Stillbirths in the United States was last reviewed in the 1992 -Year Book of Neonatal-Perinatal Medicine and it was found that significant handicap was detected in the 70% of the survivors. Poor outcome was associated with late return of the heartbeat, delayed respiration, neonatal acidemia, and the early onset of seizures.
Dr. Ingle’s comments: As far as India is concerned, we have very limited resources. I feel unless the child is very precious born after say treatment for infertility or in a very elderly patients, such efforts should not be done for a simple reason that only 36% of babies will be completely normal. Rest of the handicapped babies will be a great burden for the parents and the nation. While the team is doing resuscitated efforts, somebody must stop/counsel the relatives and if the relatives agree when the fetal heart and resuscitation are not coming back, the attempt should be left.